Tunnel Enlargement After Double-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Study

doi:10.1016/j.arthro.2008.07.018

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 24, Issue 12, December 2008, Pages 1349-1357

https://doi.org/10.1016/j.arthro.2008.07.018 Get rights and content

Purpose

The aim of this study was to compare tunnel enlargement in patients with double-bundle and single-bundle anterior cruciate ligament (ACL) reconstruction.

Methods

Sixty patients were randomized by closed envelopes into 2 different groups of ACL reconstruction with hamstring tendons: double-bundle technique with bioabsorbable screw fixation (n = 35) and single-bundle technique with bioabsorbable screw fixation (n = 25). Magnetic resonance imaging evaluation was performed in 53 patients (88%) (32 in double-bundle group and 21 in single-bundle group) for a mean of 27 months' follow-up (range, 24 to 36 months). Tunnel enlargement was determined by digital measurement of the widths perpendicular to the long axis of the tunnels on an oblique coronal and sagittal plane. The magnetic resonance imaging measurements were compared with the intraoperative drill diameter.

Results

No significant differences were found between the double-bundle group and the single-bundle group in tunnel enlargement on the femoral side. However, on the tibial side, tunnel enlargement was greater in the single-bundle group than in the double-bundle group in each tunnel (P = .051). In all knees, tunnel enlargement both on the tibial side and on the femoral side correlated significantly with the anterior and rotational laxity of the operated knee. In the double-bundle group, no tunnel communication between the anteromedial and posterolateral tunnels was seen in any of the patients on either the tibial side or femoral side.

Conclusions

This prospective, randomized study showed that our double-bundle ACL reconstruction technique results in less tunnel enlargement in each tunnel on the tibial side than the single-bundle technique with similar fixation methods, graft material, and rehabilitation. In addition, no tunnel communication was observed in the patients undergoing double-bundle ACL reconstruction. The clinical results were good in both groups. However, the patients who had more tunnel enlargement had significantly more anterior and rotational laxity of the operated knee as well.

Level of Evidence

Level I, therapeutic randomized controlled trial.

Section snippets

Patients

Sixty patients met the inclusion criteria: (1) ACL injury diagnosed by clinical examination and by MRI, (2) absence of previous ACL surgery, (3) closed growth plates, (4) absence of ligament injury to the contralateral knee, and (5) absence of multiligament injury of the knee. They were randomized by closed envelopes into 2 different groups of ACL reconstruction with hamstring tendons: double-bundle technique with bioabsorbable screw fixation (DB group) (n = 35) and single-bundle technique with

MRI at 27 Months' Follow-up

Reliable measurements were possible for all of the patients, because in the DB group, no tunnel communication between the AM and PL tunnels was seen in any of the patients on either the tibial side or femoral side. In addition, the intraobserver agreement was good. Repeated measurements showed similar results in 59% of cases, and in 41% of cases, they differed from each other by ±1 mm. Examples of the MRI examinations of the double-bundle and single-bundle ACL reconstructions are presented in

Discussion

To our knowledge, this is the first prospective, randomized study to compare tunnel enlargement between a double-bundle technique and a single-bundle technique in ACL reconstruction. Our study showed that the differences in tunnel enlargement between these 2 techniques are quite minimal. Only on the tibial side was the tunnel enlargement greater in the SB group than in the DB group in each tunnel (P = .051). In addition, unlike in the study of Siebold,¹⁴ no tunnel communication was observed in

Conclusions

Acknowledgment

The authors thank statistician Heini Huhtala, M.Sc., for statistical advice concerning this study. In addition, the help of Teppo Järvinen, M.D., Ph.D., and Sally Järvelä, M.D., is gratefully acknowledged.

References (28)

M. Ferretti et al.
The fetal anterior cruciate ligament: An anatomic and histologic study
Arthroscopy
(2007)
T. Zantop et al.
Current techniques in anatomic anterior cruciate ligament reconstruction
Arthroscopy
(2007)
T. Muneta et al.
A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques
Arthroscopy
(2007)
R. Siebold et al.
Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction
Arthroscopy
(2008)
C.D. Harner et al.
Double bundle or double trouble?
Arthroscopy
(2004)
R. Siebold
Observations on bone tunnel enlargement after double-bundle anterior cruciate ligament reconstruction
Arthroscopy
(2007)
J. Robinson et al.
Reduced bone tunnel enlargement post hamstring ACL reconstruction with poly-L-lactic acid/hydroxyapatite bioabsorbable screws
Knee
(2006)
L. Salmon et al.
Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction
Arthroscopy
(2005)
T. Järvelä et al.
Graft placement after the anterior cruciate ligament reconstruction: A new method to evaluate the femoral and tibial placements of the graft
Knee
(2001)
F.G. Girgis et al.
The cruciate ligaments of the knee jointAnatomical, functional and experimental analysis
Clin Orthop Relat Res
(1975)

A.A. Amis et al.

Functional anatomy of the anterior cruciate ligamentFibre bundle actions related to ligament replacements and injuries

J Bone Joint Surg Br

(1991)

S.L. Woo et al.

The effectiveness of reconstruction of the anterior cruciate ligament with hamstring and patellar tendonA cadaveric study comparing anterior tibial and rotational loads

J Bone Joint Surg Am

(2002)

S. Tashman et al.

Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction

Am J Sports Med

(2004)

M. Yagi et al.

Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction

Am J Sports Med

(2002)

Cited by (132)

Less tunnel enlargement in triple-bundle versus double-bundle anterior cruciate ligament reconstruction: A randomized clinical trial
2023, Journal of Orthopaedic Science
No study thus far has compared tunnel enlargement between double-bundle and triple-bundle anterior cruciate ligament reconstruction. We compared tibial tunnel enlargement and rate of tibial tunnel coalition between these two reconstructions, hypothesizing that tibial tunnel enlargement in triple-bundle reconstruction is less than that in double-bundle reconstruction, and that the tunnel coalition rate is equal between the two procedures.
This prospective randomized clinical trial included 25 patients who underwent computed tomography 2 weeks and 1 year postoperatively. Eleven patients underwent double-bundle anterior cruciate ligament reconstruction and 14 underwent triple-bundle anterior cruciate ligament reconstruction. Tunnel positions and tunnel coalition at the tibial tunnel aperture were assessed using three-dimensional computed tomography. Tunnel enlargement rate was calculated by measuring the sagittal and axial widths of the tibial bone tunnel 10 mm from the tibial tunnel aperture. These parameters were then compared between the groups.
The changes in tunnel positions and tunnel coalitions between groups were not significantly different. On both sagittal and axial views, the tunnel enlargement rates of the medial and lateral sections of the anteromedial bundle in the triple-bundle group were significantly smaller than those in the double-bundle group (sagittal view, p = 0.02 and < 0.01, respectively; axial view, p = 0.02 and ≤ 0.05, respectively). The groups did not differ significantly in terms of posterolateral tunnel enlargement.
Tunnel widening in the medial and lateral sections of the anteromedial bundle-associated tibial tunnel in triple-bundle anterior cruciate ligament reconstruction was smaller than that of double-bundle reconstruction. The tunnel coalition rates between the two reconstructions were not significantly different.
Increased Bone Plug Depth From the Joint Increases Tunnel Enlargement in Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft With Suspensory Femoral Fixation
2023, Arthroscopy, Sports Medicine, and Rehabilitation
To determine a safe bone plug depth fixation zone based on early tunnel enlargement rates in anterior cruciate ligament (ACL) reconstruction using bone–patellar tendon–bone (BPTB) autograft with suspensory femoral fixation.
Patients who had undergone rectangular tunnel ACL reconstruction using BPTB autograft with suspensory femoral fixation were retrospectively identified. Femoral and tibial tunnel aperture areas were measured on computed tomography 2 weeks and 6 months after surgery to calculate rates of femoral and tibial tunnel enlargement (FTE and TTE), respectively. Femoral bone plug depth (FBPD) and tibial bone plug depth (TBPD) were defined as the distance of the tip of the plug from the respective joint lines. Optimal FBPD and TBPD cutoff values were calculated for the following rates of FTE and TTE, respectively: 0%, 15%, 30%, and 50%.
Sixty-four patients (19 females, 45 males; mean age, 29.5 ± 12.3 years) were included in the study. The femoral and tibial tunnel apertures significantly enlarged over time. FBPD (P < .001; r = 0.607) and TBPD (P = .013; r = 0.308) were positively correlated with FTE and TTE, respectively. The optimal FBPD cutoff value was 2.8 mm for FTE rates of 0% and 15%, 3.6 mm for 30%, and 6.0 mm for 50%. The optimal TBPD cutoff value was 1.48 mm for a 0% TTE rate and 5.1 mm for those higher. The cutoff value specificities were lower for the tibial tunnel than the femoral tunnel for each tunnel enlargement rate.
Early tunnel enlargement and bone plug depth were significantly correlated in bone the femoral and tibial tunnels. The degree of correlation was higher in the femoral tunnel. To minimize bone tunnel enlargement, the distal end of the femoral bone plug should be placed less than 2.8 mm from the tunnel aperture.
Level IV, therapeutic case series
Review of Cha et al. (2005) on “Arthroscopic Double Bundle Anterior Cruciate Ligament Reconstruction: An Anatomical Approach”
2023, Journal of ISAKOS
This classic discusses the original publication ‘Arthroscopic double-bundle anterior cruciate ligament reconstruction (ACL): An anatomical approach’, the first detailed description of the surgical technique popularised by Dr Freddie Fu. The technique, in which the anteromedial and posterolateral bundles of the ACL are reconstructed individually using two grafts with independent bone tunnels, was designed to more closely recreate the function of the native ACL by more closely reproducing the functional anatomy. This reconstruction was biomechanically superior to single-bundle reconstruction, particularly with regards to rotational control, leading to great interest from ACL surgeons around the world. Clinical superiority was more difficult to demonstrate; however, and the technical difficulty of the procedure has limited its use. Nevertheless, the pursuit of improved patient outcomes through attention to functional anatomical detail continues. ‘Recreating the functional anatomy of the intact ACL remains the cornerstone of ACL reconstruction’.
The incidence of tibial tunnel coalition is higher than femoral tunnel coalition in double-bundle anterior cruciate ligament reconstruction using hamstring autografts: A systematic review
2022, Orthopaedics and Traumatology: Surgery and Research
Intra-operative and postoperative coalition of tunnels may occur in double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). However, the incidence and effect on clinical outcomes of tunnel coalition following primary DB ACLR using a hamstring autograft has yet be analyzed, and thus remains unknown. The objective of this systematic review was to identify the incidence of tunnel coalition upon DB ACLR using hamstring autografts and to elucidate any clinical outcomes and/or complications that tunnel coalition may have postoperatively.
The incidence of tunnel coalition would increase in respect to time from the index surgery, and that tunnel coalition would be related to poorer clinical outcomes compared to non-coalition cases.
Three databases (PubMed, EMBASE, Cochrane Library) were searched in accordance with PRISMA and R-AMSTAR guidelines on June 15, 2020. Relevant studies were screened in duplicate and data regarding patient demographics, incidence of femoral and tibial tunnel coalition, and outcomes were extracted. Coalition rate was also compared between follow up at 1 month or less defined as “shorter-term”, and 6 months or greater as “longer-term”. Coalition is defined as the missing of a bony bridge between the two tunnels.
Thirty-six studies examining 1,574 patients, mean age 29.1 years, were included in this study. 29 studies (1,110 knees) reported the incidence of femoral coalition with a pooled rate of coalition of 8% (95% CI = 4–12%). 28 studies (1,129 knees) reported an incidence of tibial coalition with a pooled rate of coalition of 21% (95% CI = 13–30%). The incidence of tibial coalition was significantly higher than the incidence of femoral coalition across 21 comparative studies (OR = 3.37, 95% CI = 1.41–8.09, p = 0.0065). Only two studies (111 knees) compared tunnel coalition and non-coalition groups for clinical outcome and no significant differences were observed with regards to Lysholm score, Tegner activity scale, and knee laxity measured with a KT-1000 arthrometer.
The rate of tibial tunnel coalition in DB ACLR is higher than femoral tunnel coalition, particularly at longer-term follow-up. Despite the higher radiographic evidence of coalition, the clinical effects of such remain to be ascertained, and further comparative studies are required to facilitate this understanding.
IV, systematic review.
Tibial graft fixation methods and bone tunnel enlargement: A comparison between the TensionLoc implant system and the double-spike plate
2022, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology
TensionLoc (Arthrex, Naples, Florida, USA), a tibial graft fixation system for anterior cruciate ligament (ACL) reconstruction, is expected to apply the preoperatively determined level of graft tension and allow setting of lower initial tension. Considering its mechanism, we hypothesised that TensionLoc would prevent postoperative bone tunnel enlargement (TE) through fixation with lower initial tension. Therefore, the present study aimed to compare TE between ACL reconstructions using the double-spike plate (DSP; Smith and Nephew, Andover, Massachusetts) and TensionLoc implant system.
A total of 40 patients who underwent anatomical single-bundle ACL reconstruction with a hamstring tendon graft were retrospectively analysed. In the group in which DSP and screw were used, the initial graft tension was set to 40 N at 20° of knee flexion (group D). In the other group in which TensionLoc was used, the initial graft tension was set to 30 N at 20° of knee flexion (group T). Both groups included 20 patients each. Tunnel areas were measured using computed tomography images at one week and three months after surgery, and the TE ratio was calculated according to the following equation: TE ratio (%) = (tunnel area at three months after surgery − tunnel area at one week after surgery)/tunnel area at one week after surgery × 100.
The femoral TE ratios were significantly higher in group T (80.5% ± 28.8%) than in group D (45.5% ± 34.6%) (p = 0.001). However, the tibial TE ratios did not significantly differ between the two groups.
Compared with ACL reconstruction using DSP and screw, ACL reconstruction using TensionLoc fixed the graft with lower initial tension but showed greater femoral TE and restricted knee extension in the early postoperative period.
The Graft Insertion Length in the Femoral Tunnel During Anterior Cruciate Ligament Reconstruction With Suspensory Fixation and Tibialis Anterior Allograft Does Not Affect Surgical Outcomes but Is Negatively Correlated With Tunnel Widening
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
To investigate the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using a low-dose irradiated tibialis anterior allograft with a fixed-loop cortical suspension device for the femur based on the graft insertion length (GIL) in the femoral tunnel.
Between January 2010 and January 2018, the medical records of consecutive patients who underwent arthroscopic ACL reconstruction with a tibialis anterior allograft fixed with the EndoButton CL for the femur and who had at least 2 years of follow-up were retrospectively evaluated. Patients were classified into 3 groups based on the GIL in the femoral tunnel (group 1, GIL < 15 mm; group 2, GIL of 15-20 mm; and group 3, GIL > 20 mm), and their functional scores, knee laxity, and radiographic parameters were evaluated.
A total of 91 patients were analyzed. There were no statistically significant differences in the functional scores and knee laxity between the 3 groups at 2 years postoperatively. However, significant differences were observed in tunnel widening at 1 year postoperatively in the femur (P = .045 for absolute value and P = .004 for relative value) and the tibia (P = .014 for absolute value and P = .012 for relative value), revealing that both the femoral and tibial tunnels widened as the GIL decreased. Additional linear regression analyses were performed to identify whether the GIL independently affects tunnel widening. Consequently, the femoral tunnel depth, tunnel diameter, and GIL were found to independently influence femoral tunnel widening (P = .008, P = .019, and P < .001, respectively), whereas the tunnel diameter and GIL affected tibial tunnel widening (P < .001 and P = .004, respectively).
The GIL in the femoral tunnel during ACL reconstruction using a tibialis anterior allograft with a fixed-loop cortical suspension device for the femur has no significant association with the postoperative functional outcomes and knee laxity, but it has a negative correlation with tunnel widening in the femur and the tibia.
Level III, retrospective cohort study.

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: Supported by the Medical Research Fund of Tampere University Hospital. The authors report no conflict of interest.

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Original ArticleTunnel Enlargement After Double-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Study

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Patients

MRI at 27 Months' Follow-up

Discussion

Conclusions

Acknowledgment

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Knee

Arthroscopy

Knee

The cruciate ligaments of the knee jointAnatomical, functional and experimental analysis

Clin Orthop Relat Res

Functional anatomy of the anterior cruciate ligamentFibre bundle actions related to ligament replacements and injuries

J Bone Joint Surg Br

The effectiveness of reconstruction of the anterior cruciate ligament with hamstring and patellar tendonA cadaveric study comparing anterior tibial and rotational loads

J Bone Joint Surg Am

Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction

Am J Sports Med

Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction

Am J Sports Med

Original Article
Tunnel Enlargement After Double-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Study